Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Saturday, July 26, 2014

A federal court upheld the legality of a Florida law which forbids doctors to discuss gun ownership with patients. The law, passed in 2011, was challenged as being a violation of a doctor's right to free speech. Apparently, the second amendment is more important than the first amendment. Why stop at gun ownership, perhaps every aspect of medical care should be legislated? What right does my doctor have to pester me about whether I smoke or how much I drink or whether or not I'm getting enough calcium? From the StarTribune:

The ruling by the 11th U.S. Circuit Court of Appeals in Atlanta
overturned a previous decision that had declared the law
unconstitutional. An injunction blocking enforcement of the law is still
in effect, however.The
2011 law, which had become popularly known as "Docs vs. Glocks," was
challenged by organizations representing 11,000 state health providers,
including the Florida chapters of the American Academy of Pediatrics and
the American Academy of Family PhysiciansDoctors who break the law could potentially be fined and lose their licenses.

The issue of boundaries in psychiatry is always a sticky one, and there are times when it seems prudent to bend some of the usual boundaries by a bit. Still, I tell students, readers, anyone who asks me, that the two rules one should never violate: Don't sleep with or kill you patients. Hmmm, this is a tragic story, but as the media is reporting it, a psychiatrist in a Philadelphia suburb pulled out his own gun and fired on a patient who had already shot at him and had killed his case manager. Read the NY Times account Here. The details are still unwinding.

And on to ducks:

Iraq veteran Darin Welker, pictured above, suffers from pain, depression, and post-traumatic stress, and he has found comfort from his 14 emotional support ducks. Farm animals, however, are not legal in his Ohio town, and there is a hearing to force Welker to get rid of the ducks! We at Shrink Rap say NO! Let the vet keep his support ducks! So long as he does so in a way that does not disturb others or does not endanger the ducks, we're on his side. And apparently the same town allows one therapy pot-belly pig per family, so why not some ducks? Link to the article is Here and there is a video of Welker with his ducks.

Finally, over on Clinical Psychiatry News, I responded to a reader's comment that the term "shrink" is odd and offensive. After eight plus years, I think we're moving on as the Shrink Rappers, though I am sorry it offends someone. What do you think? Read: The Stigma of Being a Shrink.

I'm going to try allowing comments again. I miss everyone's input, but I will be moderating for now.

Late
on Monday, the Broad Institute, a biomedical research center, announced
a $650 million donation for psychiatric research from the Stanley
Family Foundation — one of the largest private gifts ever for scientific
research.

It
comes at a time when basic research into mental illness is sputtering,
and many drug makers have all but abandoned the search for new
treatments.

Despite
decades of costly research, experts have learned virtually nothing
about the causes of psychiatric disorders and have developed no truly
novel drug treatments in more than a quarter century.

Broad
Institute officials hope that Mr. Stanley’s donation will change that,
and they timed their announcement to coincide with the publication of
the largest analysis to date on the genetics of schizophrenia.

Let me also encourage you to listen to the podcast linked to this article.

A family pledges one of the largest
private gifts ever for scientific research; why we may never have all
the pieces necessary for a theory of everything; sleep apnea tests can
now be taken from the comfort of your bed. David Corcoran, Michael Mason and Joshua A. Krisch

My first thought was : Really? People stop their medications all the time, cold turkey, without doctor supervision or approval, and they don't generally kill people. So how do you know if someone's "symptoms" --like agitation -- are he result of medication withdrawal, or the result of a recurrence of the original illness that the medication was treating? There's not a great way to sort that one out, but I was befuddled by the idea that one would attribute murder to medication withdrawal. Maybe that should be on the TV commercials with the list of side effects, "Stopping this medication suddenly can lead you to kill people."

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:
http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:
http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:
http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Murder accused was unable to refrain from killing the deceased because of medication withdrawal, psychiatrist tells court

- See more at:
http://www.independent.ie/irish-news/courts/murder-accused-was-unable-to-refrain-from-killing-the-deceased-because-of-medication-withdrawal-psychiatrist-tells-court-30437572.html#sthash.6SAmLiC6.dpuf

Wednesday, July 09, 2014

I've written before about shrink notes back in 2011. See Here and Here.With the increasing transparency we're seeing with electronic records, there are now systems that allow patients to access their doctor's notes. The first time one of my patients did this, he casually mentioned that the record included the wrong dose of a medication, and I suggested my patient might want to tell his doctor about this.

In psychiatry, we've been a bit touchy about this. Patients might be distressed to see what we write about them, they may see some of the terms we use to describe them (like delusional?) as being negative.

The New York Times has an article discussing a pilot study in Boston to give patients electronic access to their therapists' notes. In What the therapist thinks of you, Jan Hoffman writes:

The pilot project has
raised questions in the mental health community. Which patients will
benefit and which might be harmed? How will the notes alter a
therapeutic relationship built on face-to-face exchanges? What will be
the impact on confidentiality and privacy?

And the project
presents difficult choices for those who argue for parity between
medical and mental health patients. Should patients with schizophrenia,
for example, who may stop taking their medication after reading that
they are doing well, have the same access to treatment notes as those
with irritable bowel syndrome?

But the lingering underlying question is, do patients really want to know what their therapists think? Dr. Kenneth Duckworth,
who is the medical director of the National Alliance on Mental Illness,
an advocacy group, said: “I’ve offered to share my notes with patients
and they’ll say, ‘No, I’m good.’ But it’s a good concept that should be
researched.”

The article goes on to describe the content of some therapist's notes and the impact it has on patients to read it:

He clicked open another therapy note.

Mr. Baldwin “is
continuing to try to push himself to get out more and to be more
socially connected even while his emotions tell him to do the opposite,”
Mr. O’Neill wrote, adding that his patient is “clearly making good, and
even courageous, efforts on a number of fronts.”

Mr. Baldwin, who celebrated his birthday recently with a museum lecture, movie and dinner, flushed with pride.

Hmm, I thought. These are the type of interpretations I made aloud to the patients, they aren't the stuff of my notes, and if they were, I'd be living in the office trying to write accurate process notes of sessions. A lot goes on in a session, and notes of this type could be very long. I'd be hard pressed to feel I could prove that someone's emotions were telling them not to be socially connected and to stay inside -- what does that even mean? Oh, truth be told, I write really boring notes. In 20+ years no patient has ever asked to read their notes, and if they did, they'd find it a really boring read.

I'd love you're input, but comments are still off while the blog settles down.

Sunday, July 06, 2014

I met Dr. Sana Johnson-Quijada at the APA Annual Meeting this year in New York. Sana has her own blog Friend to Yourself, and I invited her to do a guest blog on Shrink Rap. In honor of Independence Day, she sent the following post.

Self-Care is Freedom, is Democracy, is Because We Are Accountable

It
was about 100 degrees Fahrenheit, which in my part of the world is
considered hot. But in Washington D.C., I considered that temperature
general anesthesia. I was breathing it in and trying hard to remain
alert. Just when I thought I could hold out no longer, I saw him. Big
and expressive, the long form of Abraham Lincoln was there, surrounded
by loud irreverent people. My brother and I were wiping sweat out of
our eyes trying to keep track of our kids. We wanted to read the
Gettysburg Address for our kids, and found ourselves screaming. The
kids could barely hear the words above the disinterested rabble around
us. Despite all this, I was choking; a weepy, sweaty, nearly
anesthetized but free American.

Four
score and seven years ago our fathers brought forth on this continent a
new nation, conceived in liberty, and dedicated to the proposition that
all men are created equal.

Now
we are engaged in a great civil war, testing whether that nation, or
any nation, so conceived and so dedicated, can long endure. We are met
on a great battle-field of that war. We have come to dedicate a portion
of that field, as a final resting place for those who here gave their
lives that that nation might live. It is altogether fitting and proper
that we should do this.

Just
down the corner from Lincoln is a president’s list of sites to see,
informers and reminders of who we are and where we came from. However,
none of them were “my Lincoln” experience.

But,
in a larger sense, we can not dedicate, we can not consecrate, we can
not hallow this ground. The brave men, living and dead, who struggled
here, have consecrated it, far above our poor power to add or detract.
The world will little note, nor long remember what we say here, but it
can never forget what they did here. It is for us the living, rather, to
be dedicated here to the unfinished work which they who fought here
have thus far so nobly advanced. It is rather for us to be here
dedicated to the great task remaining before us—that from these honored
dead we take increased devotion to that cause for which they gave the
last full measure of devotion…

A couple of days ago, writing the post about
how stress intersects with medicine, I remembered “my Lincoln.” It may
seem like a stretch at first but take a minute. Self-care is a way of
saying, “I am free.” In places where life is cheap, almost without
value, self-care is not much of an option. It is because of freedom
that we can extricate the meddling fingers, the invasions, and be the
keeper of our own private spaces however we choose to. It is because of
freedom that we can tell people that although my brain is ill and although I take medication, I am equal. Saying that is self-care. Saying that is possible if we
take that freedom to keep our own accountability for our own selves.
Accountability is not the same as blame. Having accountability for our
freedom is not the same as being at fault for what came before freedom, nor our current conditions.

—that
we here highly resolve that these dead shall not have died in vain—that
this nation, under God, shall have a new birth of freedom—and that
government of the people, by the people, for the people, shall not
perish from the earth.

If
you’re not accountable to your inner self, if you’re only accountable
to your actions, or you’re only accountable to what others determine and
define about you, than you are not free. You are blamed.

Accountability
is such a tender privilege. We might lose it if we forget who we are,
where we came from and our rights to freedom. Democracy is self-care.

Question: How do you see the relationship between self-care and your freedoms?

I practice psychiatry and parent, with my husband, our 3 small children.

Woven into this, writing and connection to community continues to bless me. I am grateful.